What is the role of collagen peptide, sodium hyaluronate (NaHA), and chondroitin sulphate in treating tendinopathy?

Role of Collagen Peptide, Sodium Hyaluronate, and Chondroitin Sulphate in Tendinopathy

These supplements have no established role in treating tendinopathy according to current clinical guidelines, which recommend relative rest, ice, NSAIDs, and eccentric strengthening exercises as first-line therapy. 1

Guideline-Based Recommendations

The American Academy of Family Physicians does not include collagen peptides, sodium hyaluronate, or chondroitin sulphate in their treatment algorithm for tendinopathy. 1 The evidence-based approach prioritizes:

• Relative rest for 3-6 months to prevent ongoing damage while avoiding complete immobilization 2, 3
• Cryotherapy applied through wet towels for 10-minute periods 1, 2
• Eccentric strengthening exercises to stimulate collagen production and guide normal collagen fiber alignment 1, 2, 3
• NSAIDs (oral or topical) for short-term pain relief, though they do not alter long-term outcomes 1, 2

Evidence from Osteoarthritis (Not Tendinopathy)

The EULAR guidelines address these supplements only for osteoarthritis, not tendinopathy. 1 For knee OA:

• Chondroitin sulphate showed moderate effect sizes (0.78) but may have publication bias 1
• Sodium hyaluronate (intra-articular) demonstrated pain reduction with effect sizes of 0.04-0.9 over 60 days to one year 1
• These agents may provide symptomatic benefit with low toxicity, but effect sizes are small and clinically relevant structure modification has not been established 1

Critical caveat: This evidence applies to joint cartilage pathology, not tendon pathology—fundamentally different tissue types with different healing mechanisms.

Limited Research Evidence in Tendinopathy

Recent studies suggest potential benefits, but these are not guideline-supported:

• A 2021 RCT found that oral collagen peptide type-1 combined with chondroitin sulphate, sodium hyaluronate, and vitamin C reduced pain more effectively than diclofenac in Achilles tendinopathy at 12 weeks 4
• A 2019 pilot study showed specific collagen peptides (TENDOFORTE®) combined with calf-strengthening increased VISA-A scores by 12.6 points at 3 months versus 5.3 points with placebo 5
• A 2015 RCT demonstrated that sodium hyaluronate plus chondroitin sulphate injection provided better pain and function scores than triamcinolone at 6 months in lateral epicondylitis 6

Why Guidelines Don't Recommend These Supplements

The fundamental problem: Most patients with tendinopathy (approximately 80%) fully recover within 3-6 months with conservative treatment alone. 1, 2, 7 Adding unproven supplements to an already effective treatment regimen cannot be justified when:

• No large-scale RCTs demonstrate superiority over standard care
• Mechanism of action in tendon healing remains unclear
• Cost-effectiveness has not been established
• The supplements are classified as health food supplements rather than prescribable drugs in many jurisdictions 1

Practical Clinical Algorithm

For any tendinopathy patient:

1. Initiate first-line therapy (relative rest, ice, eccentric exercises, NSAIDs for pain) 2, 3, 7
2. Continue for 3-6 months before considering any alternative interventions 1
3. If inadequate response at 3 months, consider corticosteroid injection (for acute pain only, not long-term benefit) 1, 2
4. If failure at 6 months, refer for surgical evaluation 1, 2, 3

Collagen peptides, sodium hyaluronate, and chondroitin sulphate are not part of this evidence-based algorithm.

Important Pitfalls

• Do not confuse osteoarthritis evidence with tendinopathy evidence—these are different pathologies 1
• Avoid injecting corticosteroids directly into tendon substance as this reduces tensile strength and predisposes to rupture 1
• Do not recommend complete immobilization, which causes muscle atrophy and deconditioning 2, 7
• Recognize that 80% of patients recover with standard conservative care alone, making unproven supplements unnecessary 1, 2, 7